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The relationship between physical activity and mental health, especially the symptoms of major depressive disorder (MDD) and generalized anxiety disorder (GAD), has received increasing attention in recent years.
The aim of this study was to explore the association between fulfilling the World Health Organization (WHO) global recommendations on physical activity and the risk and symptoms of MDD and GAD in the Saudi population.
This study was a secondary analysis of data from a large nationwide cross-sectional survey conducted via phone interviews in June and July 2020. In this study, a proportional quota sampling technique was used to obtain an equal distribution of participants, stratified by age and gender, across the 13 regions of Saudi Arabia. The main mental health screening tool used for the risk of MDD was the Patient Health Questionnaire-9 (PHQ-9). Risk of GAD was measured using the Generalized Anxiety Disorder-7 (GAD-7) scale. Participants self-reported whether they fulfill the WHO global recommendations on (1) moderate-intensity aerobic physical activity (MIPA) and (2) vigorous-intensity aerobic physical activity (VIPA). The results were then analyzed based on the following two categories: fulfilling the WHO global recommendations or not.
The data analysis included 8333 participants recruited in the main study between June and July 2020. The response rate was 81.45% (8333/10,231). Of them, 50.3% (4192/8333) were female, and the mean age was 36.5 years, with a median age of 36 years and a range from 18 to 90 years. The average total PHQ-9 score was 5.61, and the average total GAD-7 score was 4.18. For men, the average total PHQ-9 and GAD-7 scores were associated with fulfilling recommendations for MIPA; however, there were no associations for VIPA in both sexes. Fulfilling the WHO’s recommendations for MIPA was associated with considerably fewer depressive symptoms in six of the nine items in the PHQ-9. Moreover, fulfilling recommendations for MIPA was associated with considerably fewer anxiety symptoms in six of the seven items in the GAD-7. However, fulfilling recommendations for VIPA was significantly associated with more depressive symptoms in one of the PHQ-9 items (“Thoughts that you would be better off dead or thoughts of hurting yourself in some way;”
This study has shown that fulfilling guidelines on MIPA is associated with less overall risk of MDD and GAD in males and fewer depressive and anxiety symptoms generally in a nonclinical population. In the general population, an increase in MIPA may improve well-being and general mental health.
The World Health Organization (WHO) has recognized health as “A state of complete physical, mental, and social well-being and not the absence of disease or weakness” [
Physical activity is recognized as a key factor in the prevention and management of mental illness, including, but not limited to, mental disorders such as major depressive disorder (MDD), generalized anxiety disorder (GAD), and posttraumatic stress disorder [
A recent meta-analysis of prospective cohort studies demonstrated in subgroup analyses that depression could be reduced by 22% if participants complete 150 minutes per week of MIPA [
This study was a secondary analysis of a multiwave, cross-sectional, national-level mental health screening (Saudi Mental Health Surveillance System) completed via computer-assisted phone interviews conducted in two waves between June and July 2020. The full methodology and rationale were previously published as a study protocol article [
Adults aged 18 years or above from Saudi Arabia were recruited via a random phone number list generated from the Sharik Association for Health Research, a research participant database [
This surveillance system used a proportional quota sampling technique to achieve an equal distribution of participants, stratified by age, gender, and region within and across the 13 administrative regions of Saudi Arabia. The Saudi Mental Health Surveillance System uses two age groups based on Saudi Arabia’s median adult age of 36 years. This led to a quota of 52 for this study.
The sample size was calculated based on the depth of the subanalysis needed for the surveillance system, which compares age and gender groups across regions with a medium effect size of approximately 0.3, 80% power, and a 95% CI [
The data used in this secondary analysis included general demographic variables, such as age, gender, and region, and other health-related variables, such as a history of mental health conditions and physical activity.
Physical activity was assessed by asking the participants on how many days they performed the recommended levels, duration, and intensity of physical activities within the previous week, using two brief assessment tools for physical activity. For VIPA, the question was “how many times a week do you usually do 20 minutes or more of vigorous-intensity physical activity that makes you sweat or puff and pant?” (eg, heavy lifting, digging, jogging, aerobics, and fast bicycling). For MIPA, the question was “how many times a week do you usually do 30 minutes or more of moderate-intensity physical activity or walking that increases your heart rate or makes you breathe harder than normal?” (eg, carrying light loads, bicycling at a regular pace, and doubles tennis) [
To categorize the participants’ physical activity, this study used the WHO’s global recommendations on physical activity for adults (18-64 years old), which are in line with guidelines from the Centers for Disease Control and Prevention and the American Heart Association [
The PHQ-9 score is the total score of nine questions, each of which is answered on a 4-point Likert scale ranging from 0 to 3, for a final total score between 0 and 27. Similarly, the GAD-7 score is calculated as the total score of seven questions, each of which is answered on a 4-point Likert scale ranging from 0 to 3, for a final total score between 0 and 21.
Quantitative variables are presented by mean if they have a normal distribution or by median and range, as appropriate, and compared using the
Ethical approval was obtained from the Sharik Association for Health Research institutional review board (approval number 01-2020).
The data set included 8333 participants from two waves (June and July 2020). The response rate was 81.4% (8333/10,231). The mean age was 36.5 years, with a median age of 36 years and a range from 18 to 90 years.
Participant characteristics.
Characteristic | Value (N=8333), n (%) | |
|
|
|
|
Male | 4141 (49.7) |
|
Female | 4192 (50.3) |
|
|
|
|
Asir | 643 (7.7) |
|
Baha | 625 (7.5) |
|
Eastern Region | 645 (7.7) |
|
Hail | 646 (7.8) |
|
Jazan | 645 (7.7) |
|
Al Jouf | 638 (7.7) |
|
Madinah | 641 (7.7) |
|
Makkah | 648 (7.8) |
|
Najran | 643 (7.7) |
|
Northern Boarder | 639 (7.7) |
|
Qassim | 648 (7.8) |
|
Riyadh | 643 (7.7) |
|
Tabuk | 629 (7.5) |
|
|
|
|
Yes | 191 (2.3) |
|
No | 8142 (97.7) |
|
|
|
|
Yes | 130 (1.6) |
|
No | 8203 (98.4) |
The average total PHQ-9 score was 5.61, and the average total GAD-7 score was 4.18. As shown in the
Independent samples
Variable | 150+ min MIPAa/week |
|
||
No (n=6961) | Yes (n=1372) | |||
Mean PHQ-9b score | 5.69 | 5.15 | 3.96 (8331) | .001 |
Mean GAD-7c score | 4.33 | 3.95 | 3.06 (8331) | .002 |
aMIPA: moderate-intensity aerobic physical activity.
bPHQ-9: Patient Health Questionnaire-9.
cGAD-7: Generalized Anxiety Disorder-7.
Independent samples
Variable | 75+ min VIPAa/week |
|
||
No (n=7326) | Yes (n=1007) | |||
Mean PHQ-9b score | 5.63 | 5.40 | 1.48 (8331) | .137 |
Mean GAD-7c score | 4.28 | 4.20 | 0.50 (8331) | .614 |
aVIPA: vigorous-intensity aerobic physical activity.
bPHQ-9: Patient Health Questionnaire-9.
cGAD-7: Generalized Anxiety Disorder-7.
In terms of the differences between males and females, in the PHQ-9 score for males, there were significant differences with MIPA (
In the GAD-7 score for males, there were significant differences with MIPA (
MIPA was associated with considerably fewer depressive symptoms in six of the nine items in the PHQ-9 (
Independent samples
PHQ-9a items | 150+ min MIPAb/weekc |
|
|||
No (n=6961) | Yes (n=1372) | ||||
Little interest or pleasure in doing things | 0.79 | 0.67 | 4.78 (8331) | <.001 | |
Feeling down, depressed, or hopeless | 0.81 | 0.70 | 4.64 (8331) | .001 | |
Trouble falling or staying asleep, or sleeping too much | 0.95 | 0.93 | 1.03 (8331) | .30 | |
Feeling tired or having little energy | 0.96 | 0.88 | 3.06 (8331) | .002 | |
Poor appetite or overeating | 0.72 | 0.68 | 1.57 (8331) | .12 | |
Feeling bad about yourself — or that you are a failure or have let yourself or your family down | 0.46 | 0.42 | 1.65 (8331) | .10 | |
Trouble concentrating on things, such as reading the newspaper or watching television | 0.47 | 0.43 | 2.02 (8331) | .044 | |
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual | 0.37 | 0.32 | 2.82 (8331) | .005 | |
Thoughts that you would be better off dead or thoughts of hurting yourself in some way | 0.17 | 0.13 | 2.89 (8331) | .004 |
aPHQ-9: Patient Health Questionnaire-9.
bMIPA: moderate-intensity aerobic physical activity.
cThe scores of PHQ-9 items are provided.
Independent samples
GAD-7a items | 150+ min MIPAb/weekc |
|
||||
|
No (n=6961) | Yes (n=1372) |
|
|
||
Feeling nervous, anxious, or on edge | 0.77 | 0.72 | 2.33 (8331) | .02 | ||
Not being able to stop or control worrying | 0.54 | 0.46 | 3.56 (8331) | <.001 | ||
Worrying too much about different things | 0.61 | 0.55 | 2.28 (8331) | .02 | ||
Trouble relaxing | 0.70 | 0.64 | 2.27 (8331) | .02 | ||
Being so restless that it’s hard to sit still | 0.41 | 0.36 | 2.75 (8331) | .006 | ||
Becoming easily annoyed or irritable | 0.80 | 0.77 | 1.10 (8331) | .27 | ||
Feeling afraid, as if something awful might happen | 0.50 | 0.44 | 2.70 (8331) | .007 |
aGAD-7: Generalized Anxiety Disorder-7.
bMIPA: moderate-intensity aerobic physical activity.
cThe scores of GAD-7 items are provided.
The data are available from Sharik Association for Health Research upon request.
This study explored the association between WHO global recommendations on physical activity for mental health and the risks of MDD and GAD in a Saudi community population sample. It is one of the first and largest studies to explore the association between physical activity and risk of mental health disorders (MDD and GAD) in general population settings in Saudi Arabia. The study found that the average total PHQ-9 and GAD-7 scores were associated with fulfilling recommendations for MIPA among men only; however, there were no associations for VIPA in both sexes. Further analysis showed that the associations of fulfilling MIPA with PHQ and GAD were only significant for males. MIPA was associated with considerably fewer depressive symptoms in six of the nine items in the PHQ-9. Moreover, MIPA was associated with considerably fewer anxiety symptoms in six of the seven items in the GAD-7 scale. None of the anxiety symptoms (GAD-7 items) was associated with VIPA. On the other hand, VIPA was associated with considerably fewer depressive symptoms in three of the nine items in the PHQ-9. However, VIPA was associated with more depressive symptoms in the self-harm and suicide ideation item of the PHQ-9.
MIPA has been shown to have a significant association with better mental health in several other studies across many countries, confirming its cross-cultural effectiveness [
VIPA is generally associated with better mental well-being, including coping, autonomy, and personal growth [
One strength of this study was the exploration of the association between physical activity and individual symptoms of depression/anxiety, as mental health symptoms may differ in their etiology, risk factors, impairment, etc, and thus may show differential associations with physical activity [
This study was limited by its cross-sectional design, which prevented the analysis from generating the direction of the association between physical activity and the risks of MDD and GAD. The study was also limited by its bivariate analysis, which may be affected by other behavioral factors. However, it provided initial insights on the effect of physical activity on mental health in a general community setting in Saudi Arabia, which adds to the global literature in this area of research. The findings of this study may be relevant to other countries with high levels of physical inactivity like Saudi Arabia, but generalization of the results to other countries may be limited.
This study found that fulfilling guidelines on MIPA (150 min/week) is associated with lower depression scores among male participants and generally fewer depressive and anxiety symptoms. Increasing the general population’s awareness of the need to increase moderate physical activity levels may improve the population’s mental health.
generalized anxiety disorder
Generalized Anxiety Disorder-7
major depressive disorder
moderate-intensity aerobic physical activity
Patient Health Questionnaire-9
vigorous-intensity aerobic physical activity
World Health Organization
The authors would like to express their gratitude and appreciation to King Abdulaziz City for Science and Technology for providing the research grant for this study (grant number 5-20-01-000-0001).
NFB, NAA, and MHB participated in the conceptual design and formulation of the research questions. All authors participated in the development and review of the manuscript. NAA supervised and managed the data collection process. NAA and NFB analyzed the data.
None declared.